International Journal of Person Centered Medicine, Vol 1, No 1 (2011)

FROM THE THIRD GENEVA CONFERENCE ON PERSON-CENTERED MEDICINE:
THE TEAM APPROACH IN PERSON-CENTERED HEALTH CARE

The Team Approach in Person-centred Health Care: The Social
Work Perspective

Terry BamfordOBE MA(Oxon) Dip(Soc Admin) FRSA

International
Federation of Social Workers; Former Chairman, British Association of Social
Workers, London, UK.

Abstract

Social workers bring to the
multidisciplinary team skills in direct relationship work, experience of group
work and an awareness of wider social factors affecting the patient. They have
a particular role in working with relatives and carers to establish a network
of support which is critical after discharge from hospital. If the traditional
ambivalence of social work towards medicine and the medical model can be
overcome social workers can improve the overall effectiveness of team
functioning.

Correspondence Address

Introduction

‘No man is an island’ wrote John
Donne in 1624. Today we all claim to be team players and recognize that what we
are able to achieve depends on the contribution of many others.

The nature of the interaction of clinicians and social
workers with their patient or client will in large measure be shaped by the
contribution of others. A friendly welcome from the receptionist, comfortable
chairs, and something to read while waiting to see the doctor or social worker
set the tone for the consultation. They also enhance the prospects of a useful
interview and mutual understanding. At the other extreme the theatre porter,
nursing staff and anaesthetists are essential components of the multi
disciplinary team in surgery.

Social Work and Medicine

Social work operates at the boundary
between the individual and their environment. It tries to reduce the pressures
caused by poverty, poor housing and fractured relationships and the impact
which these have on health outcomes. Social workers have to work through others
to achieve positive outcomes for those with whom they are working.

Modern medicine places the patient at the heart of the
process. There has been a transformation in the nature of the doctor-patient
relationship. The NHS Alliance affirmed “The
relationship between GPs and patients should be an equal one, to empower the
patient to be ‘fully engaged’ (in the Wanless Report’s terminology) in caring
for their own health as much as they can” [1]. This welcome endorsement
of patient participation has been reflected in increasing openness in the
communication between clinicians and patients.

The rapid development of the internet has been a major
driver of change with a proliferation of web sites enabling patients to
research their own condition, to establish mutual support networks and
sometimes to challenge clinicians with details of new clinical trials of which
the doctor may be unaware. The power balance is shifting and in a way which is
not always comfortable as knowledge ceases to be the exclusive prerogative of
the professional.

But welcoming increasing self-management of long-term
conditions and greater patient participation is not enough. Equality between
doctor and patient means that it is important unequivocally to accept the
patient as a full member of the multi disciplinary team. If we practice
person-centred care then by definition the patient is the core member of the
team and should be involved in all decisions about treatment.

Of course not all team members have equal status. As
Napoleon said in Animal Farm ‘all pigs are equal, but some are more equal than
others’ [2]. Status comes from experience, age and professional discipline.
Historically medicine has been viewed as the leading profession within the team
with others in a subordinate role. That view is still widely held. Tuso in an
American context asserted “the future success of our
physicians, as leaders of their teams, will depend on how well we identify and
train physicians in the art of leadership. Our growth and success will
depend on strong leadership developing a culture of strong leadership. The
physician as leader carries responsibility” [3]. Person-centred medicine stands
this on its head by asserting that the person with most authority in the team
is the patient.

There is a distinction between leadership and authority.
Decisions about care and treatment should not be taken without the agreement of
the patient. This is not to pretend that patients have the same knowledge and
experience of other professionals in the team, nor the same understanding of
risks and consequences. But the responsibility of other team members is to
ensure that their understanding is fully shared with the patient so that an
informed decision can be made about management and treatment of the condition.

The Value of Social Work

Social work values are wholly
congruent with this approach. They emphasise both self-determination and
participation.

“1. Respecting the right to
self-determination - Social workers should respect and promote people’s right
to make their own choices and decisions, irrespective of their values and life
choices, provided this does not threaten the rights and legitimate interests of
others.

2. Promoting the right to
participation - Social workers should promote the full involvement and
participation of people using their services in ways that enable them to be
empowered in all aspects of decisions and actions affecting their lives” [4].

So what does this mean for the role of social workers in
multi disciplinary teams?. Social workers have a crucial role in the team in
ensuring that the views of the patient are heard at every stage of the process.
How they do this will vary from team to team. Sometimes no more may be required
than gentle encouragement to the team to involve the patient. At other times
where patients lack mental capacity or are unable clearly to articulate their
views they may be acting more in the role of advocate for the patient seeking
to act in their best interests [5].

Often it is in arrangements for discharge from hospital that
social workers will become involved. This is where their knowledge of social
welfare benefits, accommodation and employment comes into play. Adequately
heated and clean accommodation suitable for the needs of the discharged patient
is essential if discharge is not to be swiftly followed by readmission.
Arrangements need to be made with the employer or in the absence of work with
social security to ensure an adequate income. Carers whether through the family
or the social network need to be mobilized and supported with a clear
understanding of their role and where they in turn can seek support and assistance.

Social Work, Relatives and Carers

Relatives and carers have a crucial
role. While they are not directly involved as part of the team they have
equally to be involved and informed about the treatment plan, its risks and its
consequences. The relatives and friendship network can be viewed as an outer
circle of support helping the team achieve successful outcomes. By virtue of
their links with the family and carer network social workers will be
particularly active in helping them to understand and deal with the fear and
anxiety which surrounds any medical intervention.

Some diseases carry particular fears for both patients and
their carers. Cancer has a special resonance with its associations of death,
physical decay and pain. Social workers are used to helping people face up to
often painful realities. They do so fortified by the practice knowledge that
acknowledging a problem is the key to being able to deal with it making the
problem more manageable. Social workers have to work with the psychological
impact of life-threatening conditions and can help the patient to address their
fears.

Social Work and Recovery

In terms of physical recovery after
surgery or illness these social factors are well recognized. They are however
even more true for mental well being where the individual needs sensitive help
to build upon strengths and develop resilience. Again this is where social work
has a distinctive contribution. Social workers mediate between potential
stresses in the environment and the patient to ensure that difficulties are
minimized and strengths are built upon and reinforced.

Mental health recovery is not a
clinical absence of symptoms. A broader conceptualization is needed. The
recovery model has been widely adopted. Within this approach recovery is viewed
as a personal journey. Hope, a sense of self-worth, supportive relationships,
empowerment, social inclusion, coping skills, and finding meaning in life are
the component elements. In a joint statement the Royal College of
Psychiatrists, Social Care institute for Excellence and Care Services
Improvement Partnership offered this definition [6] “Recovery is the process of
regaining active control over one’s life, accepting and coping with the reality
of any ongoing distress or disability [7], resolving personal, social or
relationship issues that may contribute to one’s mental health difficulties,
taking on satisfying and meaningful social roles, and calling on formal and/or
informal systems of support as needed [8].

These areas are the territory in
which social workers operate.

Social workers have expertise in
working with relationships. This is both the personal relationship with their
clients but also helping their clients with their own troubled and difficult
relationships. They have experience of working with users and carers to strengthen
support mechanisms.

This expertise in direct relationship work with the patient
is a key skill which social workers bring to the multidisciplinary team. They
will often be the only professional in the team with explicit training in group
work and can use that knowledge to help the team address conflicts and
difficulties.

Social Work and Preconditions for Effective Teamwork

The pre-conditions for effective
teamwork are well recognised. These are:

·Clear shared aims and
goals

·Focus on results

·Competent team members

·Unified commitment

·Collaborative climate and
mutual respect

·High standards and clear
expectations

·External support and encouragement

·Principled leadership [9]

Clarity about the aims of the team is essential. But too
often these are implicit. As Sir Kenneth Calman wrote about aims “they need to
be hammered out, discussed, debated and by joint agreement put into practice”[10].

Mutual respect cannot always be assumed. Historical
professional rivalries or personal conflicts can destabilize a team. High
functioning teams need a mechanism for resolving differences. Team members
bring different skills but they should be valued equally. While respecting the
individual skills of the disciplines represented in the team, the best teams
have a flexibility which allows some blurring of boundaries. Teams supporting
people with mental health problems are a good example where the psychologist,
nurse, social worker or psychiatrist may at times have interchangeable roles.

Information is power but that is true only if information is
freely shared within the team. Good teams pay attention to their internal
communication mechanisms. That does not just mean the distribution of
information but also the opportunities to reflect and discuss the significance
of the information. In a health care setting confidentiality and how it is
handled can be a source of tension. Clarity is needed about who are the team
members, what stays within the team and what can be shared outside.

All team members have a shared responsibility to promote
open communication

Teamwork does not come naturally. It has to be worked at and
constantly reinforced. Social work can help the team work to the benefit of the
patient. There are three key roles; as an advocate for the patient, as an
interpreter of the patient’s views to the team and of the team’s views to the
patient, and in using negotiating skills to help the team communicate
effectively.

Conclusion

Social work’s relationship with
medicine has been characterized by ambivalence. The clinical model of
diagnosis-prescription-treatment-recovery does not accord with the experience
of social workers who tend to take something closer to a public health model
looking at the wider determinants of health- poverty, bad housing, poor
nutrition, and unemployment- as contributing to poor health outcomes. That
perspective can assist the multidisciplinary team in taking a wider view.

Teamwork is not easy. Sharing decision making with patients
is not easy. But a team working effectively can bring real gains for the
patient both in terms of outcome and the positive effect of being taken
seriously as a co-producer in the health care enterprise.